Breast Reconstruction
and Augmentation
Using Pre - Expansion
and Autologous
Fat Transplantation
Roger Khouri, MDa, Daniel Del Vecchio, MDb,*
KEYWORDS
 Breast reconstruction  Breast augmentation
 Fat grafting  Fat transplantation
The concept of fat grafting for volume enhance-
ment is not a new one. Although surgeons have
been injecting fat for years,1,2 recent focus by clini-
cians3 and basic science investigators has gener-
ated a groundswell of enthusiasm for a ‘‘back to
the science’’ approach to fat transplantation.
There is much to study to maximize both graft
volume and, more importantly, patient safety.
This article outlines the authors’ approach to
breast deformities using fat grafting, with
emphasis on current technique.
FAT GRAFTING: HARVESTING
After Illouz’s4 seminal paper describing the ability
to remove fat cells from small port incisions using
a cannula, liposuction offered surgeons a low-
morbidity new supply of autologous filler. Because
many of the variables so important to fat grafting
were not well understood at that time, early results
were disappointing as it related to volume
maintenance.
One of the most frustrating outcomes plastic
surgeons experience is often in fat grafting. Despite
the same surgeon, the same technique, and the
same recipient site, there is a wide variability
among volumes maintained over time (Fig. 1).
Donor age, donor site, harvesting technique and
instrumentation used with harvesting, processing
technique, injection technique, and recipient site
management both pregrafting and postgrafting
a
Dermatology and Plastic Surgery, Key Biscayne, FL, USA
b
Back Bay Plastic Surgery, 38 Newbury Street, Boston, MA 02116, USA
* Corresponding author.
E-mail address: dandelvecchio@aol.com (D. Del Vecchio).
Clin Plastic Surg 36 (2009) 269–280
doi:10.1016/j.cps.2008.11.009
0094-1298/08/$ – see front matter ª 2009 Published by Elsevier Inc.
are all vitally important to the success of fat graft-
ing and to maintenance of volume.5 Looking to the
science in the organ transplantation literature may
help standardize techniques in this area.
Intuitively, donor (and recipient) age is thought
to be a factor in the success of fat grafting. Animal
studies in nude mice suggest this to be the case.6
Data from human fat over a range of donor ages in-
jected subcutaneously into nude immunocompro-
mised mice, suggested higher volume retention in
recipients with fat from younger donors. In prac-
tice, autologous fat grafting does not afford the
opportunity to control for this variable and this
may only serve as a prognosticator for patients
preoperatively.
Harvesting techniques vary greatly in liposuction
and certainly impact cell survival and graft take.
Several studies have demonstrated that less
suction results in more viable adipocytes.7 Gener-
ally, handheld syringe methods are thought to
traumatize adipocytes less and are recommended
to harvest fat. In addition, smaller-gauge syringes
are recommended so as to avoid fat clumping
and to ease in reinjection.
Ostensibly, one might think that surgically re-
sected fat, which is then diced with minimal
trauma, maintains cellular integrity better than suc-
tioned fat by any method, and results in better
plasticsurgery.theclinics.com
graft take.8 Ongoing studies are being performed
in this area to understand better the role of mini-
mizing graft trauma9 and there is an opportunity
270 Khouri & Del Vecchio

(3g–5g forces) trauma or excessive syringe manip-

ulation (Fig. 2).
Subjecting adipocytes to air can potentially
damage the cells and can decrease their survival.
In addition, the time between harvesting and rein-
jection increases duration of hypoxia and poten-
tially has an effect on adipocyte survival. Such
concerns support the argument that fat grafting
in large volumes (unlike those performed for lip
or nasolabial folds) might best be accomplished
with a team approach. Ostensibly, it is recommen-
ded that an assistant or several assistants process
fat simultaneously while surgical liposuction
harvest is performed.

INJECTION TECHNIQUE
Fig. 1. Fat grafting. Current variables. Injection technique also varies and probably plays
a role in fat grafting survival. Bolus injections are to
to validate this question and potentially to improve be condemned because they defeat the purpose
instrumentation in this area. of oxygen diffusion and usually result in fat lique-
faction, necrosis, and oil cysts. Dispersing the fat
as evenly as possible into as many interstices as
FAT PROCESSING possible in the recipient tissue theoretically gives
the donor cells the highest chance of maintaining
There have been multiple reports of ‘‘percent graft
an oxygen diffusion gradient over the critical 3 to
take’’ by volume.10 Because of lack of standardi-
5 days postgrafting.
zation in grafting technique, clinicians must
There are currently several preferred techniques
consider rethinking the results of many of these
of grafting fat into the breast. The authors’
studies. Sixty milliliters of aspirated fat using the
preferred technique, the ‘‘mapping’’ technique,
tumescent technique decants to a variable aliquot
involves the use of small (3-mL) syringes handheld
of fat and serum, including blood and crystalloid.
and connected directly to a 16-gauge blunt nee-
Sixty milliliters of aspirate may decant to 30 to
dle. Markings are made in the recipient areas
40 mL of fat. When this fat is then centrifuged or
(Fig. 3) to aid in a systematic injection. An exact
rolled on a Telfa pad, two techniques used to
amount of fat (1–2 mL) is then injected slowly on
concentrate fat further, the resultant fat may
withdrawal. The needle is then inserted into
reduce to 20 mL by volume. It is not surprising
another adjacent tunnel and the process is
that when fat is grafted, even if all the fat survives,
repeated. This technique is more deliberate and
in many cases one has already committed to at
exact but does take more time. In addition, it
best a 30% to 40% volume take, because that is
requires the operator to deploy the plunger and
the actual amount of fat that has been inserted
withdraw the needle at the same time.
by volume.
Although separation by simple decanting uses
1g to separate higher-density blood and crystal-
loid from adipocytes, a high-speed centrifuge
uses much higher gravitational forces (3g–5g)
and separates fat from crystalloid extremely well.
These centrifuges also require transfer of fat into
multiple individual 5- or 10-mL syringes. It has
been demonstrated, however, that subjecting
adipocytes to 3g to 5g of centrifugation results in
a higher degree of cell death.11 A compromise
between these two techniques that the authors
use is manual centrifugation. Prototype devices,
similar to the geared concept used in salad spin-
ners, can subject larger volumes of adipocytes to
1g to 2g forces to separate out unwanted crystal- Fig. 2. Manual centrifugation in closed IV collection
loid better, without subjecting the fat to excessive bag system.

Fig. 3. Mapping technique of fat injection.
A second technique is the ‘‘reverse liposuction’’
method. A 30-mL syringe containing prepared fat
is connected to short intravenous extension tubing
and is connected to an injection needle. An assis-
tant depresses the plunger at a desired rate (as
directed by the surgeon) while the surgeon
focuses only on the motion and location of the
needle. In this manner, a large volume of fat can
be randomly dispersed into the recipient site in
a shorter period of time. It is vitally important to
keep the needle under motion at all times and to
keep the injection speed low to avoid bolus injec-
tions. When starting out with fat grafting to the
breast the mapping technique is generally
advised. To date there are no data suggesting
one technique is superior.
Because many reports suggest at best 30% fat
take, one controversy in fat grafting has been
whether or not to overcorrect. Overcorrection
historically seemed alluring because one might
reach a desired end point knowing a significant
amount of adipocytes would not survive. It is
believed, however, that the increased interstitial
pressure created in most cases results in lack of
oxygen diffusion and cell death, potentially of all
the cells.
Indeed, some of the best clinical results in fat
grafting have been demonstrated by those who
promote small serial volume sessions of fat graft-
ing. The evidence suggests that this approach is
successful because it respects the interstitial pres-
sure limitations of the recipient site and in doing
so, promotes diffusion during the initial critical
days postgrafting.
THE ROLE OF THE RECIPIENT SITE
Recipient site management has only recently been
suggested as a potential important variable in fat
Breast Reconstruction and Augmentation 271
grafting. From the general surgery trauma litera-
ture and from hand and upper extremity trauma,
the importance of compartment pressure and
grave consequences of interstitial pressure are
well understood. If it is possible to increase the
volume of the interstitial space before fat grafting,
it is potentially feasible to inject a larger volume of
graft into the recipient site before reaching high
interstitial pressures.
Experience with the vacuum-assisted closure as
a means of wound management has proved that
microangiogenesis is a direct result of negative
mechanical pressure.12 The extensive vacuum-as-
sisted closure data on vascular in-growth coupled
with the MRI findings from BRAVA-expanded
breasts support the authors’ thesis that increased
microcirculation, combined with the larger intersti-
tial space created by the expansion, may both
contribute to the potential for increased fat
volumes and increased diffusion gradients.
Although such postulates are currently being
considered for animal study, mechanical difficul-
ties related to immobilization of vacuum domes
on animal subjects remain a significant challenge
(Fig. 4).
The BRAVA bra was initially developed in the
1990s to generate a nonsurgical negative pressure
breast enhancement. The device generates
a negative pressure that creates an inflow of fluid,
in this case interstitial fluid, and increased vascu-
larity. The device was typically worn nightly under
a low negative pressure, and over 4 to 6 weeks
breast enlargement of a cup size on average was
achieved. Once the device was discontinued
from use, however, breast size regressed to the
pre-expansion baseline.
When used as a recipient site modulator before
fat grafting, pre-expansion is thought to generate
a more supple skin envelope, especially in recon-
struction cases and in cases of irradiated tissue.
In addition, the increased interstitial space is
believed to allow for a larger volume of fat to be
grafted while still dispersing the cells with
oxygen-rich recipient site tissue. Clinically, the
authors aim for a twofold to threefold increase in
volume before grafting (Fig. 5).
Postoperatively, skin grafts are immobilized to
promote secure apposition of the donor cells to
the recipient wound bed. This promotes an
adequate diffusion gradient and greater likelihood
that angiogenesis occurs. Searing of the graft or
movement of any type in this initial 3 to 5 days
can prove fatal for a skin graft. It is believed that
immobilization of the transplanted adipocyte can
best be accomplished with mild external negative
pressure. The authors are currently advocating
use of the BRAVA bra for 5 to 7 days postgrafting.
272 Khouri & Del Vecchio

Fig. 4. VAC data demonstrate increased circulatory flow with negative pressure (top left). (Data from KCI.) The
theoretical effect of negative pressure on breast circulation (top right). MRI of breasts pre-expansion (bottom
left). Postexpansion using BRAVA (bottom right). Note the real increase in vessel caliber and number
postexpansion.

Not only does the mild negative pressure serve to
immobilize the fat in its interstitial space, it also
may help with angiogenesis as has been demon-
strated with the vacuum-assisted closure. Lastly,
the domes of the external expander BRAVA unit
help protect the newly grafted tissue from external
movement and trauma.
IMPROVED INSTRUMENTATION
In 1980, when Illouz first described the liposuction
technique, 10-mm cannulae were described. Thirty
years later, clinicians are now rapidly removing fat
using 12-gauge cannulae with multiple side ports,
in a less traumatic manner (Fig. 6).

Fig. 5. A threefold to fourfold volume expansion of the recipient site is possible and desirable before fat grafting.

Fig. 6. Commonly used 12-gauge cannula for fat harvesting.
CELL PRESERVATION TECHNIQUES FROM
TRANSPLANTATION LITERATURE
In the solid organ transplantation, cell preservation
is maximized by hypothermia and extracorporeal
perfusion during organ transfer using a variety of
solutions. One such solution, University of Wiscon-
sin Solution,13 is a highly concentrated potassium
solution that reduces cellular metabolism in the
solid organ during its period of cellular hypoxia
and anoxia, and is thought to reduce cellular death
following reperfusion in the recipient site. This
highly concentrated potassium solution is not
used in vivo, but is used to perfuse the solid organ
while in transit and in preparation for transplanta-
tion. In general surgery shock and trauma, a variety
of solutions are known to improve reperfusion and
improve cell survival following resuscitation. These
represent just a few starting points for several
potential strategies that are suitable for study for
possible adoption in maximizing techniques of fat
transplantation. Current research is underway to
identify optimal solutions in this area.14
BREAST RECONSTRUCTION AND
AUGMENTATION: THE EMERGING ROLE
OF THE RECIPIENT SITE AND FAT GRAFTING
The State of Mastectomy Surgery
in the United States
Annually in the United States, there are approxi-
mately 182,000 newly diagnosed cases of breast
cancer that require some type of surgical proce-
dure to treat breast cancer.15 These generally
represent some form of mastectomy or lumpec-
tomy; however, there are approximately 57,000
breast reconstructions performed a year in the
United States.16 If one assumes that all these
reconstructions are performed for immediate (or
in the same year of the mastectomy) reconstruc-
tion, at best only 31% of patients are receiving
some form of breast reconstruction. This number
is probably lower because many of the reconstruc-
tions are performed on cases diagnosed and
surgically treated in prior years. This also means
that every decade, approximately 1.2 million
women are electing to do nothing about their post-
surgical breast deformity. Why do such a high
percentage of breast cancer surgery patients elect
to do nothing following lumpectomy or mastec-
tomy? One postulate is that the degree of
morbidity of the reconstruction outweighs the
Breast Reconstruction and Augmentation 273
perceived aesthetic improvement over the existing
deformity.
In this orphaned population, a low-morbidity
procedure to reconstruct breast defects that
results in significant aesthetic improvement repre-
sents a large opportunity.
The State of Breast Augmentation
Surgery in the United States
An adequate discussion of augmentation with
breast implants is beyond the context of this
article. It is interesting to consider, however, the
risk-reward analysis similar to that outlined in the
patient after breast cancer surgery.
Reviewing available statistics, there were
approximately 348,500 cosmetic breast augmen-
tations performed in the United States in 2007. In
addition, retail data from Consumer Reports
suggests that at least 34% of women in the United
States own padded bras.17 Based on standard
assumptions about the United States population
and the percent of women of adult age, for every
women who undergoes a cosmetic breast
enhancement, there are over 100 women who,
for whatever reason, would like their breasts to
appear larger in some way. The same rational for
nonsurgery (padded bras) may also exist as it
does for breast reconstruction. Besides financial
issues, concerns over artificial implants, and other
personal concerns, a remaining variable is that the
degree of morbidity of the augmentation does not
outweigh the aesthetic improvement over the ex-
isting aesthetic concern. As in the case of recon-
struction, a low-morbidity procedure to augment
breasts that results in significant improvement
represents a large number of potential patients,
much larger than the reconstruction population.
Patient Evaluation: Medical
The patient presenting for breast reconstruction or
augmentation with autologous fat grafting should
be evaluated for associated medical conditions
that might otherwise exclude them from safely
undergoing a liposuction procedure. Acutely, the
liposuction aspect of the intervention is probably
higher in morbidity than that of the breast fat graft-
ing. Smokers are generally not advised as candi-
dates for breast reconstruction with fat grafting
with pre-expansion. Donor site fat is evaluated
for the likely availability of fully processed fat.
274 Khouri & Del Vecchio
Irradiated patients have been successfully treated
using BRAVA pre-expansion. In irradiated recon-
structions, the skin envelope expands more slowly
and serial expansion and injection sessions are
required. It is generally advised to begin breast
reconstruction in nonirradiated mastectomy
patients and first become familiar with these tech-
niques before embarking on treating irradiated
defects. The assessment of the opposite breast
is addressed with the same principles as for any
breast reconstruction.
Patient Evaluation: The Role of Compliance
Animal studies with negative pressure pre-expan-
sion are challenging because of difficulties main-
taining a device in animal subjects. The same can
be said for patients with regards to BRAVA pre-
expansion. There is no substitute for sustained
moderate to high negative pressure pre-expansion
to maximize pre–fat grafting volume of the recipient
site. Indeed, the earliest versions of the negative
pressure pumps were low-voltage battery-oper-
ated devices that exerted a low negative pressure.
These patients exhibited less dramatic pregrafting
expansion when compared with more powerful
pumps currently used. These pumps are similar in
negative pressure and in terms of size and porta-
bility as the vacuum-assisted closure pump, and
have demonstrated a dose response curve with re-
gards to both pre-expansion volume and to overall
fat volume results postgrafting.
Based on experience with the dose response
data, the authors believe there is no substitute
for adequate pre-expansion. The degree and
extent of pregrafting expansion is directly propor-
tional to the amount of grafting possible to main-
tain a physiologic interstitial pressure. Last
minute ‘‘cramming’’ on part of the patient has
been experienced and does not result in success-
ful preparation. It is ultimately the responsibility of
the surgeon adequately to select, educate, coach,
and troubleshoot their patients to ensure adequate
and optimal pre-expansion. Patients should spend
as much time in-office the first time they use their
bras to ensure they are properly educated and
motivated to use the device.
BASELINE VOLUME CONSIDERATIONS
The more breast and subcutaneous tissue there is
to begin with, the easier it is to volume expand with
negative pressure. In addition, the less scar
damaged (nonirradiated) the tissue is, the easier
it is to expand with negative pressure. The
following cases serve as extreme examples
(Box 1).
Box 1
Examples of baseline volume considerations
Case A: Augmentation
Existing breasts, 250 mL size. Desired final
breast volume, 500 mL. Plan: pre-expansion to
desired volume, then graft. Percent expansion
5 (500–250)/250 5 100%.
Case B: Reconstruction
Existing breast skin, subcutaneous fat 50 mL
size. Desired volume, 500 mL. Plan: pre-expan-
sion to desired volume, then graft. Percent
expansion 5 (500–50)/50 5 900%.
The number of sessions for Case A may be one,
whereas the number may be four to five for
Case B.
Preferred Techniques
BRAVA: recipient site preparation
In cases of mastectomy and for augmentation, the
BRAVA dome is placed for 3 to 4 weeks and is
worn 12 hours daily. For the last 4 to 5 days before
fat grafting, it is advised to wear the domes 24
hours a day. Circumferential pressure at the edges
of the domes can create skin sensitivity and this
should be explained to patients who should
reduce the degree of negative pressure. Nonirradi-
ated skin and subcutaneous tissue has greater
potential for parenchymal expansion than cases
performed in irradiated tissue, which requires
more serial sessions (Fig. 7).
The location and degree of body fat available is
analyzed to evaluate the existence of an adequate
amount of donor fat. Because there are so many
variables (amount of tumescence, degree of
bleeding, time allowed for tumescent solution to
set) it is impossible to formulate a standard ratio
of aspirate to actual processed fat by volume. As
a conservative rule, four to five times the desired
volume of fat needed for grafting should be avail-
able to be harvested as aspirate. For example, if
reconstruction using 400 mL of fat is planned,
the patient should be able to render at least 1600
to 2000 mL of aspirate to ensure adequate donor
material.
Aspirate 5 5  Graft; 2000 mL 5 5  400 mL
Considering the pre-expansion effort the patient
must tolerate, it is always better to have more than
less fat available.
In the case of augmentation with 300 mL of fat
on each side, a minimum of 3000 mL of aspirate
is recommended. Patients with body mass
indexes as low as 23 to 24 have been successfully
 Breast Reconstruction and Augmentation 275

Fig. 7. Augmentation (top), mastectomy (middle), irradiated mastectomy (bottom) sites with pre-expansion. After
3 to 4 weeks, note the varying range of expansion possible in each category.

treated. The lower the body mass index, the
greater the number of donor sites (abdomen,
knees, thighs, and so forth) that must be entered
to harvest adequate amounts of aspirate and fat.
Lipografting: preoperative planning
On the day of surgery patients are photographed
and marked as usual for liposuction. Markings
are made for injection sites on the breasts and
lines are made on the breast mound to ensure
proper dispersion of the fat grafts. Patients are
brought into the operating room still wearing the
BRAVA bra to maximize expansion closer to the
point of injection. Once all the fat is harvested
and processed, the Bra is removed, the site is
prepared and redraped, and injection takes place.
Harvesting and collection
Fat is harvested using a 12-gauge blunt cannula
with multiple side ports. Syringe aspiration is
used as opposed to high negative pressure
machine techniques. To avoid desiccation,
276 Khouri & Del Vecchio
a closed system is used, transferring the fat from
the syringe directly into an empty sterile intrave-
nous bag by an extension tubing setup (Fig. 8).
Processing
Once an adequate amount of aspirate is har-
vested, the collected intravenous bags are dec-
anted of unwanted fluid and are placed into
a manual centrifuge. This manual centrifuge further
separates fluid from the adipocytes without sub-
jecting the cells to excessive handling, desicca-
tion, or trauma, as is postulated with high-speed
centrifugation in small syringes.
Once the fat is properly processed in this
manner, the fat is then drawn back into 3- or
5-mL syringes from the intravenous collection
bags using a three-way stopcock, and grafting
begins.
Recipient site techniques: needle band release
Multiple radial needle insertions are made around
the breast mound to disperse the grafted adipo-
cytes maximally and to ensure as many different
planes as possible. Before grafting the fat, if there
are breast shaping issues that need to be ad-
dressed these can be performed at this time.
In many breasts, fibrous ligamentous tissue or
bands distort the breast mound, such as in con-
stricted inframammary folds or in the case of
tubular breast deformities. Because expansion of
the parenchymal space places these bands under
high tension, it facilitates the transaction of these
bands using an 18-gauge needle, simply by insert-
ing the needle in the area of the band and through
proprioception, ‘‘feeling’’ the blade of the needle
cut the band. In this manner, it is possible to
‘‘expand’’ or ‘‘release’’ these constrictions further
internally in a manner similar to the external
release of a burn scar contracture. The inframam-
mary fold can be lowered in constricted inframam-
mary folds, and the constricted bases of tubular
breasts can be widened in this manner. It is
Fig. 8. Closed system method of collection and fat replantation.
important not to overrelease these bands,
because too large a dead space might ensue.
This reduces the interstices of the tissue and
reduces the surface-to-volume characteristics of
the recipient site.
Injection technique
Bolus injections are to be condemned because
they defeat the purpose of oxygen diffusion and
usually result in fat liquefaction and necrosis.
The mapping technique previously described
involves the use of small (3-mL) syringes handheld
and connected directly to a 16-gauge blunt nee-
dle. Through the multiple radial needle insertions
around the breast mound, the needle is advanced
in the subcutaneous plane and an exact amount of
fat (1–2 mL) is then injected slowly on withdrawal.
The needle is then inserted into another adjacent
tunnel and the process is repeated.
Injection into the prepectoral fat and the subcu-
taneous fat is performed in as many different depth
planes as the recipient tissue tolerates. In the case
of mastectomy, the first session of grafting allows
fewer planes of grafting and reasonable volumes
during the first session (150–250 mL) should be
planned. For subsequent sessions, there are
more potential planes, because a thicker intersti-
tial space exists. Generally, the more parenchyma
one has to begin with, the larger volumes of fat that
can be grafted. For first session reconstruction
after mastectomy, 150 to 250 mL of fat can be ex-
pected. For augmentation or in subsequent graft-
ing sessions in reconstruction, 200 to 300 mL
can be planed. For irradiated cases, one should
be extremely careful not to overgraft and should
expect a minimum of four to five sessions.
In no cases (breast augmentation, treating
a lumpectomy defect, breast asymmetry, or any
other cases where any breast tissue remains) is it
ever recommended to inject fat directly into breast
tissue.

POSTOPERATIVE MANAGEMENT
Patients are instructed to wear the BRAVA bra 5 to
7 days postgrafting. This potentially helps with
graft immobilization, potentiates neovasculariza-
tion, and definitely protects the breast from
external pressure or trauma.
REPRESENTATIVE RESULTS
Breast Reconstruction
The patient in Fig. 9 had bilateral mastectomy
(radical on the right) and had four serial sessions
of BRAVA pre-expansion and fat grafting sessions
of 150 mL each time.
Breast Reconstruction for Severe Asymmetry
The 20-year-old patient in Fig. 10 had a giant
congenital nevus excised as a child and demon-
strated hypomastia on the left, documented
Fig. 9. Patient with bilateral mastectomy and BRAVA pre-expansion reconstruction; three sessions, 600 mL total.
Breast Reconstruction and Augmentation 277
by MRI. She underwent 3 weeks of BRAVA
pre-expansions to increase her parenchymal
space and to increase the vertical skin envelope
deficiency. She underwent a single session with
grafting of 300 mL into the left breast. Her postop-
erative result at 6 months reveals retention of
grafted fat volume.
Breast Augmentation: Postpartum Deflation
The 33-year-old patient shown in Fig. 11 desired
larger breasts after having several children and
experiencing some mild deflation. Although she
wore a padded bra and desired a cup size
increase in volume, she did not wish to have breast
augmentation with implants. She underwent
3 weeks of BRAVA pre-expansions to increase
her parenchymal space bilaterally. She underwent
a single session with grafting of 250 mL into
278 Khouri & Del Vecchio

Fig.10. (A) Patient with severe breast asymmetry and BRAVA pre-expansion reconstruction. (B) BRAVA pre-expan-
sion increases parenchyma and skin envelope. (C) Six months after 280 mL of fat transplanted into the left breast.
 Breast Reconstruction and Augmentation 279

Fig. 11. The patient is shown pre-expansion (left) and 9 months after fat grafting (right).

each breast. At 9 months postgrafting, she
demonstrates adequate volume maintenance.
A COMPARISON OF BREAST RECONSTRUCTION
USING THREE TECHNIQUES
Table 1 helps delineate some of the main differ-
ences between currently popular reconstruction
options and breast reconstruction using pre-
expansion and autologous fat transplantation.
Imaging and Detection of Breast Cancer
In 1987, the American Society of Plastic Surgeons
position paper strongly condemned fat grafting to
the breast suggesting fat grafting would distort the
ability of breast cancer detection. Breast fat graft-
ing has been demonstrated to sometimes result in
microcalcifications.18 Although many of these
calcifications are believed to be distinguishable
from calcifications of higher grade that are
suggestive of malignancy, unnecessary biopsies
have resulted from this effect.

CONTROVERSIAL TOPICS
At the time of this communication, it is early days in
breast augmentation and reconstruction using fat
transplantation. There are more questions than
there are answers, and it is easier to ask than to
answer the questions. The following represent
some of the biggest controversies and challenges
facing this technique in the near, medium, and
long term.
Risk of Cancer: The Aromatase Question
It is well known that one in nine women experience
breast cancer in their lifetime. Although it takes
a nearly impossible study size to prove causality
or statistical significance, the question has been
raised that aromatase, a breakdown product of
adipocyte necrosis, might cause breast cancer.
The validity of this is unknown.

Table 1
Differences among breast reconstruction options

Tissue Expander/Implant TRAM BRAVA

Pain level Moderate High Low
No. procedures 2 1–2 1–4
General anesthesia 2 1–2 0–1
Office visits for 3–5 None None
expansion
Expansion type Serial, office based None Continuous
Recipient site skin Thinned NA Thickened
Hospital days 0–1 3–5 None
Donor site morbidity NA High Liposuction, bonus
Patient compliance Patient passive Passive Compliance is key
Reoperation tolerance Moderately possible Unlikely Simple
Cost to system Moderate High Low
280 Khouri & Del Vecchio
What is known is that surgeons have performed
thousands of procedures over the past 20 years in
large numbers that cause fat cell necrosis. Despite
thousands of TRAM flaps, with a high degree of fat
necrosis in zone II and III, breast liposuctions, and
breast reductions, there is no evidence, retrospec-
tive or prospective, that these procedures are
associated with a higher degree of breast cancer.
Such facts should not be sufficient, however, as
to ignore the question of safety. Although there are
currently models being developed to evaluate this
carcinogenic potential in an animal model, the
reality is that the answer in humans will not be
available before the widespread use of this tech-
nique. Any patients entertaining any breast fat
grafting, including reconstruction patients and
breast augmentation patients, must be given full
informed consent as to the unknown risks of the
technique. Although many suggest this technique
not be performed without the approval of an
internal review board, the reality is that the tech-
nique is already being performed.
There is an unmet clinical need for more institu-
tional review board–approved, multisite studies
that can demonstrate reproducible and safe
results by many independent surgeons. Such
collective data in the literature will eventually help
delineate the safety issues as they relate to carci-
nogenesis and cancer detection.
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